Mothers, Babies, Midwiives: With Woman in Kathmandu

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A change of focus has brought some new perspectives. I had a week in the mountains. (To donors, please know that this was personal time and therefore personal money. Your donations are kept for midwifery work only) Awe-inspiring panoramas, infinite steps and some ambivalence. Trekking in Nepal is nothing like long distance walking in Europe or hiking in the wilderness in the United Stated. The endless steps connect the mountain villages to which there is no vehicular access at all. Everything is brought in on the backs of ponies or people (wearing flip-flops, which is an improvement over when my sister Sara went trekking 30 years ago and they were barefoot). Tourists are herded into “teahouses” which are village guestshouses of a basic sort. Despite the beauty of the mountain views, a certain sadness pervaded the trek. The early morning is the time of clear air and great views. Within a few hours the cloud/mist enshrouds everything and the mountains disappear. The moisture makes the melancholy mood, the damp is pervasive, and the poverty and tourists make a disturbing mix. The largest national group seen on the treks is the Chinese. They seem to surpass the Americans in loudness and enormous cameras.

I met several Tibetan Nepalis and received a bit of an education on thier lack of rights. They are denied refugee status due to pressure from China and even those who have been here 60 years or were born here have no rights in Nepal: no official right to work or vote, no passport or travel documents. They exist by working around the system which in this country is kind of what everybody is doing anyway, but…. no way to live. Poor Nepal squeezed between India and China seems totally stuck. And talking politics, there is an election for the Constitutional Assembly here on the 19th. Some of the Maoists, who fought and won a civil war are against the election (they might lose) and are planning strikes. It seems that the strikes are not a popular idea so they may not come off. I hope they don’t… Had it a bit with holidays! However there is concern that if they lose the election they may not relinquish power and, well, it could get complicated. The recent political history here is dramatic in the extreme. For the bizarre story of the massacre of almost the entire royal family in 2001 by one of the princes, follow this link.

Today I met with Kersten at United Nations Population Fund(UNFPA). She is a Swedish midwife, whose mission is to strengthen the midwifery profession in order to improve maternal child health outcomes. I was looking for her help in promoting the use of the anti-shock garment. About that she was encouraging and gave me more contacts, but about midwifery in Nepal she is a bit pessimistic. The bureaucratic and political barriers are great. Karma and caste maintain the status quo.

I drew back the curtains one morning last week, and the air was clear. The mountains rose behind the houses. And there behind them… were the real mountains, the snow-capped Himalayas right outside my window. They had been hidden every other day by smoggy haze. Hooray, a clear sharp view of snowy peaks puts the smile on any morning face.

So through the city to the birth center. All is well. Things are happening despite glacial slowness. Why use one person to do something when 3 will do? Decide to go to buy the flooring for the birth room at last but wait there is a phone call then someone comes round with an important piece of paper to sign which involves much thinking and rereading and then of course there is another cup of tea and finally off on the errand we go. That’s the way it is. The task of getting the brochure printed is mammoth. Misunderstandiings about who is doing what and how it should be done… days pass. Leisurely dysfunction.

The story of Ratna sadly exemplifies the way it is in Nepal. She is a nurse with a few months’ midwifery training like most of the staff at the center. She wants to study more and finish her Bachelors in Nursing. Last week she told me that her grades weren’t good enough and she was on the waiting list. I commiserated. Today Rashmi told me the full story. Most applicants are wait-listed she said. Those that are accepted from the list are those who pay. Ratna can’t pay. Rashmi tried to use her influence, without paying, a little string-pulling but to no avail. No pay no place.

On a more hopeful note, I think I have found someone who will “champion” the non-pneumatic anti-shock garment in Nepal. It will need a champion to push its use, spread the word, inform, instruct, and cajole. Asa works part time at APS as well as full time at the big public hospital. She told me that she became a midwife because of her mother. Her mother died at the age of 33 of a postpartum hemorrhage. We weren’t talking about the anti-shock garment when she told me about her mother. We have not talked much. I am not sure why she told me about her mother. It was emotional and hard to talk about. Strange that she told me. Then I told her about the anti-shock garment. The anti-shock garment impressed her. She knows it will saves mothers’ lives.

And I want to tell all you deviners out there, Nepal is a place where it is apparently impossible to lose things because someone will find it for you. From my little flashlight which I left in a crowded restaurant and was returned to me 3 days later, to my camera which I lost at the Boudenath stupa and was returned to me by a delightful Nepali child. And a bag of precious goodies I had bought were carefully rescued for me by a guard at the Golden Temple in Patan.

The festival of Dashain lasts 15 days! The build-up was fun. There was the buzz of shoppers, travellers, preparation. Then there was the height of the festival: ritual, puja, tika, food. And then… it went on. Many shops still closed. Not much getting done. Personally, I had a case of Dashain fatigue. I wondered if the Nepalis felt the same. I had the feeling that some of them did.

I continued working at the birth center through the holiday. It was quiet but a bit of action here and there. Babies get born whatever is happening and the clinic is always open. But today the festival is over and despite being saturday which is the Nepali weekend, I had a much-anticipated meeting with Kiran at the Midwifery Society of Nepal and feel energized in new directions. We had a wonderful two hours together. She described her struggles for acceptance for the profession of midwifery and the resistance of both physicians and nurses (a sad and old story). She is working towards an in-hospital birth center (more like a midwifery led unit in the UK) which can serve as a model midwifery care site and as a clinical setting for midwifery students. We planned my continuing education topics. I will do a series of weekly hour-long sessions to the society through November. The first will be (surprise surprise) childbirth education and adapting teaching models to Nepal. The second will be on the topic of the anti-shock garment. Hooray! The third will be on birth centers and there may be a fourth on finding and using evidence for midwifery care practices. So lots of prep for me for those workshops lies ahead. Of course I continue to work with Rashmi and the midwives at APS Birth Center.

So now a few pitures. First shoving the sacrificial goats into a variety of vehicles!

We are a wandering species. Wandering and shared culture is mutually strengthening. One of my personal goals on this trip is to be tipped off-balance by new experiences, different people and places, and to gain personally from this. As I wrote in one of my earliest posts (“Intercultural Understanding July 29th” https://wiwok.wordpress.com/2013/07/ ) “I believe that help is a minefiled”. My whiteness and my American experience give my words and my ideas power that I do not intend. I am treated with a deference that is both natural hospitality and a discomfitting honor that belies a very mixed intercultural history.

Bringing ideas and teaching imply a negative assessment of midwives and APS Birth Center. A negative assessment does not mean criticism. There is no blame given. But I know it is felt. And that feeling weakens the confidence of those struggling here under very difficult circumstances. It disempowers them and makes them more dependent. So, what if I didn’t try to do what I am doing? What if all the do-gooders walked out of Nepal and left them to their own devices? Maybe they would be better off and midwifery, mothers and babies would figure out quite happily how to care for themselves. Such abstract questions are meaningless and absurd, however, in a globalised and interdependent world. The strength of technological systems deriving from corporate power are such that the marginalised, the midwives and normal birth would lose. So I continue to tiptoe around the minefield.

As part of the promotional materials we are creating for the birth center, I asked a couple of the midwives to translate a piece called “What a midwife does”. This proved extremely difficult. Despite an online dictionary, translations were elusive. Most difficult of all…. the word “midwife”. In Nepal, English words are often used for things of a technical or maybe prestigious nature. (This sometimes leads to both the sense that an individual Nepali’s English is bettter than it is, and also sometimes to the feeling that you understand things that are being said when you actually do not). Thus, Nepali midwives like the term “midwife” to describe themselves even though it is in English and ordinary Nepalis do not really know what it is. They do know the word “daiamma” which means literally “with mother” and also the word “sudani” which means community health worker (I think). But neither of the words satisfy the midwives at APS. The “daiamma” is an untrained village traditional birth attendant and the sudani is not right either. So they choose midwife. I understand but I am sad. I am sad that the word “daiamma” which is clearly related to so many words for midwife in so many languages (partera, sagefemme, meyaledet, hebamme) has been tarnished with the reputation of the untrained. How can midwifery in Nepal be professionalised if it cannot claim it’s name?

Prena struggling with the translation

Rashmi has decided that with my help (our help, thank you donors), she would like to make a few physical changes at the center. I am relieved. She is so modest with her ideas. We walked down the hill from the center to the carpenter’s shack. He will put up a movable partition to help the flow of the center. Currently most people walk through the pharmacy to get into the main building. It doesn’t really make sense. The carpenter and Rashmi seem to be old buddies and after planning the changes we wandered a few steps behind the shack to his house for cups of tea with his wife and sister. They have a sewing business in their home and quickly whippped out the tape measure, spread out the cloth and had me measured for a “kurta” before I knew what was going on.

I’m hanging out here in Kathmandu. I’m a routines kind of person. And I’m develping my routines. My quiet breakfasts. Organizing to go over to the birth center. What will I be bringing with me? What will we be working on? Wandering through the town to the bus. Last week or so I learnt that buses make sense. A cab is a bargain at $3 but it was my biggest daily expense! At 15 cents, it’s hard not to get a bus. And it feels a lot safer than a taxi. It’s bigger and it sticks to the bigger roads (much less picturesque and less bumpy). So it takes longer to get to the birth center. But I’m in no hurry. I love my wander/walk through Tahity (called Tahity??) and via a mini-monkey temple called Kathesimbhu Stupa

Kathesimbhu Stupa

and via the square with a temple that honors the tooth protecting deity

I think this is the tooth guy but not sure. Fierce anyway

and the veggie sellers of Asan Tole, and the crazy pre-festival shoppers, to Ratna Park where the foot traffic squeezes through a toothpaste tube and up onto the footbridge where people sit and sell flip-flops and watches, and a beggar plays listlessly on a drum and someone else is begging for a kidney transplant, to my bus. They squeeze us in cozily and off we go. Kalanki is dusty, dirty and busy. I walk a few minutes towards the birth center, and today before going in, I took a few pictures of the goat market opposite. Goats to be sacrificed for the Dashain festival

Today at the birth center, I was planning to prepare three topics for a meeting with Kiran, the president of the Midwifery Society of Nepal: 1) A presentation on Childbirth Education (I seem, bizarrely, to be becoming an “expert” on this topic) 2) A presentation on the anti-shock garment, it’s benefits, research to support it’s use in shock secondary to postpartum hemorrhage. I really believe in this thing and hope that Kiran will be inspired to push it to the Nepali Government and 3) Some topics in evidence based maternity care. I was supposed to meet with her at 3 and worked away at my prep but then she cancelled on me till next week. That’s kind of the way things go here, so I worked with the birth center midwives on posterior babies and other topics. We’ve had a good few days at the center. A Nestle man (boo, hiss) came to present on nutrition in pregnancy, and while we were all somewhat stimulated by some of it, I was also inspired to prepare my own nutrition power point! (of course). Here are some midwives listening to the Nestle (boo, hiss) man:

Here is more childbirth ed stuff: preparing material:

Prena and Laxmi

And here is a gorgeous Nepali lady smiling as she gets a depo shot!!!

And here are two delightful midwives bravely preparing to head home on their motor bikes

Ferst day of the Dashain holiday which is 15 days long! It seems day 1 days 7,8,9, and 10 are the highlights. Rituals and stories seem very complicated. Durga…. one of the many mothers, is the heroine and sacrifices play a part. Lots of people travel to be with family (It’s kind of like Christmas/Seder night I think) Lots of people were out shopping. Being both Saturday and a festival, I didn’t go to the birth center but instead, dedicated myself to Kathmandu tourism. Been here 3 weeks and decided it was high time to see the monkey temple. I did a lot of walking in the rain: Up to Swayambhunath (monkeys and staring eye stupa) and then back down over the river and through the alleyways to Durbar Square which I had visited on my first day in a jet-lagged fog. Great food and alleyways clogged with festival shoppers and back wet, muddy, satisfied.